Sample - General survey

Form Approved

OMB No. 0923-0051

Exp. Date 02/28/2021

Appendix E: General Survey

Interviewer__________ Household ID___________ Participant ID ___________

Date _____________ Start time _____________ End time ______________

Participant Name: ____________________________________________________

SECTION I: ADULT SURVEY

General Survey Module: Location/Exposure

From now on, I will refer to the [Description of Incident] on [Date] as “the incident.”

1. I would like to know about your exposure inside the highlighted area on the map between [Incident Date] at [Time] and [End Date/Time].

Public reporting burden of this collection of information is estimated to average 28 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-0051)

What is the address of where you were the longest during the incident? Probe for as much location information as possible. Then, continue to b.	Street address City, State Zip Other location information
How long were you in this location? circle whether in minutes or hours.	_____ minutes hours
Did you receive instructions to shelter in place? If respondent said “yes” go to d, if “no” continue to e:	Yes No Unsure
Please describe what you did to shelter in place.
Did you smell an odor? If no or unsure skip questions f and g.	Yes No Unsure
Can you please describe the odor?	Gasoline Rotten eggs Chemical Smell Paint or paint thinner Bug spray Smoke Sewage Other______
Would you describe the odor as light, moderate or severe?	Light Moderate Severe
Did you come in contact with any of the following?	Smoke Dust Debris Hazardous substance Unsure Other___________

2. Did you evacuate from the highlighted area on the map?

Yes

No Go to Question 5

3. At approximately what time did you evacuate?

____:_____ AM PM

Hour Min

4. How did you evacuate?

Ambulance

Privately-owned vehicle

Bus

Other (Please specify):

5. Were you decontaminated, meaning your clothing was removed or your body was washed?

Yes

No Go to next module

6. How were you decontaminated? Read all answer choices aloud to the respondent and check all that apply.

Clothing Removal

Water

Soap and Water

Other (Please specify):

7. Where were you decontaminated? If respondent needs clarification, specify that this question is asking for a geographic location, not a place on their body. Read all choices to the respondent.

Community reception center (CRC)

Mobile decontamination unit

Emergency room (ER)

Other (Please specify):

8. At approximately what time were you decontaminated?

____:_____ AM PM

Hour Min

General Survey Module: Health Status after the Incident

1. I’m going to ask you some questions about symptoms that could be related to the [Incident]. This list should be narrowed down ahead of time with a toxicologist or physian or other expert. Fill out the table provided below. Completei-iii for one symptom before asking about the next symptom.

	Did you experience [Symptom] since the incident? If yes, go to ii. If no, repeat i for next symptom.		If you experienced this [Symptom] before the incident did it get worse?		Are you still experiencing [Symptom]? Repeat i for next symptom.
Symptom	Yes	No	Yes	No	Yes	No
GENERAL
Fever
Chills
Generalized weakness
Body pain
Severe bleeding
EYES
Increased tearing
Irritation/pain/ burning of eyes
Blurred vision/double vision
Bleeding in eyes
EAR/NOSE/THROAT
Runny nose
Burning nose or throat
Nose Bleeds
Hoarseness
Increased salivation
Ringing in ears
Difficulty swallowing
Swollen neck
Pain in jaw
Odor on breath (Gasoline or other, specify)
Stuffy nose/sinus congestion
Increased congestion or phlegm
NERVOUS SYSTEM
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures or convulsions
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Difficulty concentrating
Difficulty remembering things
Concussion
Loss of balance
MUSCLE/JOINT/BONES
Weakness of arms
Weakness of legs
Joint swelling
Muscle weakness
Muscle twitching
Tremors in arms or legs
Joint pain
Broken bone/fracture
Dislocation
Sprain or strain
Whiplash
HEART AND LUNGS
Breathing slow
Breathing fast
Difficulty breathing/feeling out-of-breath
Coughing
Wheezing in chest
Slow heart rate/pulse
Fast heart rate/pulse
Chest tightness or pain/angina
Bronchitis
Pneumonia
Burning lungs
STOMACH/INTESTINES
Nausea
Non-bloody vomiting
Non-bloody diarrhea
Bloody vomiting
Blood in stool/diarrhea
Abdominal pain
Fecal incontinence or inability to control bowel movements
Bowel perforation
SKIN
Irritation, pain, or burning of skin
Skin rash
Hives
Skin blisters
Bumps containing pus
Nail changes
Hair loss in area of rash
Hair loss
Dry or itchy skin
Sweating
Cool or pale skin
Skin discoloration
Poor wound healing
Petechiae/Pinpoint round spots
Blue coloring of ends of fingers/toes or lips
Lips turning blue
Abrasion/scrape
Bruise
Cut
KIDNEY/BLADDER
Urinary incontinence or dribbling pee
Inability to urinate or pee
Blood in urine
Painful urine
PSYCHIATRIC
Anxiety
Agitation/irritability
Thoughts of suicide
Fatigue/tiredness
Difficulty sleeping
Difficulty staying asleep
Feeling depressed
Hallucinations
Paranoia
Unexplained fear
Tension or nervousness
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

General Survey Module: Optional Mental Health Screeners

Generalized Anxiety Disorder 7 ( GAD 7)

Over the last 2 weeks, how often Not Several More Nearly

have you been bothered by the at all days than half every

following symptoms? the days day

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

3. Worrying too much about different things 0 1 2 3

4. Trouble relaxing 0 1 2 3

5. Being too restless that it is hard to sit still 0 1 2 3

6. Being easily annoyed or irritable 0 1 2 3

7. Feeling as though something awful might

happen 0 1 2 3

Generalized Anxiety Disorder 7 (GAD7) Scoring System

GAD-7 Score Level of Anxiety

0 – 4 Minimal

5 – 9 Mild

10 – 14 Moderate

15 – 21 Severe

Screening Questionaire for Disaster Mental Health (SQD)

People who have experienced the incident often report that their lives have changed dramatically and they are constantly under various kinds of stress. Have you experienced any of the symptoms listed below in the past month?

Q1. Have you noticed any changes in your appetite? 1. Yes 0. No

Q2. Do you feel that you are easily tired and/or tired all the time? 1. Yes 0. No

Q3. Do you have trouble falling asleep or sleeping through the night? 1. Yes 0. No

Q4. Do you have nightmares about the event? 1. Yes 0. No

Q5. Do you feel depressed? 1. Yes 0. No

Q6. Do you feel irritable? 1. Yes 0. No

Q7. Do you feel that you are hypersensitive to small noises or tremors? 1. Yes 0. No

Q8. Do you avoid places, people, topics related to the event? 1. Yes 0. No

Q9. Do you think about the event when you do not want to? 1. Yes 0. No

Q10. Do you have trouble enjoying things you used to enjoy? 1. Yes 0. No

Q11. Do you get upset when something reminds you of the event? 1. Yes 0. No

Q12. Do you notice that you are making an effort to try not to think about the

event, or are trying to forget it? 1. Yes 0. No

[ Score ]

SQD-P: Q3 + Q4 + Q6 + Q7 + Q8 + Q9 + Q10 + Q11 + Q12 = __________________

SQD-D: Q1 + Q2 + Q3 + Q5 + Q6 + Q10 = _______________________

[ Guidelines ]

SQD-P: 9-6 = Severely affected (possible Acute Stress Disorder (ASD))

5-4 = Moderately affected

3-0 = Slightly affected (currently little possibility of ASD)

SQD-D: 6-5 = More likely to be depressed

4-0 = Less likely to be depressed

General Survey Module: Medical Care

1. Did you receive medical care or a medical evaluation because of the incident?

Yes  Go to Question 3

No

2. Why didn’t you seek medical care?

Did not have symptoms    

Symptoms were not bad enough    

Don’t like to go to the doctor

Didn’t want to take time

Worried about who would pay for the medical visit

Worried about losing job

Other (Please specify): ______________________________________________

Unsure

For those individuals who did not seek medical care, go to the next module.

3. Please tell me if any of the following describe why you sought medical care. Read questions a-c to the respondent and circle the appropriate answer(s).

1. You were given instructions to seek medical care? Yes No Unsure

2. You experienced health problems or symptoms
   within 24 hours of the incident? Yes No Unsure

3. You were worried about possible health
   problems associated with the incident? Yes No Unsure

4. How did you receive medical care Can Check more than 1?

EMT or paramedic

Hospital  Go to Question 5

Doctor or other medical professional  Go to Question 15

4. On what date were you first provided care at a hospital? If you had any additional visits to the hospital, please provide me the dates of those visits. Record the date that the respondent first went to the hospital and then the date of any subsequent visits.

1^st date of hospital visit: ____/____/______

MM DD YYYY

2^nd date of hospital visit: ____/____/______

MM DD YYYY

3^rd date of hospital visit: ____/____/______

MM DD YYYY

4. What is the name and city of the hospital(s)?

Hospital 1_____________City 1 ______________________

Hospital 2 ____________City 2_______________________

Hospital 3 _____________City 3______________________

4. How did you get to the hospital? If the respondent had more than one hospital visit, tell them that you are referring to their first visit.

EMS/Ambulance

Drove self

Driven by relative, friend, or acquaintance

Other (Please specify):

4. Were you treated only in the emergency department or were you admitted to the hospital?

Treated in emergency department (Outpatient)  Go to Question 15

Admitted (Hospitalized)

4. How many nights were you hospitalized, including any nights in an intensive care unit (ICU)?

________ Nights

4. Were you placed in an Intensive Care Unit or ICU?

Yes

No  Go to Question 15

4. How many nights were you in the ICU?

________ Nights

4. Were you on a ventilator?

Yes

No  Go to Question 15

4. How many nights were you on a ventilator?

________ Nights

4. If aged 18 or older, read: To improve future responses, we try to study medical emergency response as thoroughly as possible. Are you willing to let us get a copy of your medical records for the medical treatment you received because of the incident?

Yes  Review the medical records release form with the respondent and collect their signature

No

4. Read i–iv to the respondent and record information in the table below.

On what dates were you provided care by a doctor or other medical professional? (mm/dd/yyyy)	What is the name of the doctor or other medical professional?	What service did this doctor or medical professional provide?	What is the address of the office?

General Survey Module: Medical History

Now I’m going to ask you a few questions about illnesses you may have had and the kinds of medicines you may have used.

1. Prior to the incident, have you ever been told by a doctor or other health care provider that you have or had any of the following medical conditions? You can narrow down the table below in consultation with a toxicologist or physician if these conditions do not seem relevant to the exposures. Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical Condition
Allergies?	Yes (Please specify) ______________________ No Unsure
Asthma?	Yes No Unsure
Depression?	Yes No Unsure
Anxiety?	Yes No Unsure
Diabetes?	Yes No Unsure
High blood pressure?	Yes No Unsure
Chronic obstructive pulmonary disease (COPD) or emphysema?	Yes No Unsure
Heart Disease?	Yes No Unsure
Physical disability that hinders mobility?	Yes (Please specify)_______________________ No Unsure
Psychological condition such as anxiety, depression or dependence disorder?	Yes (Please specify) ______________________ No Unsure
Cancer?	Yes (Please specify) _____________________ No Unsure
Immune disorders such as lupus, rheumatoid arthritis, or HIV?	Yes No Unsure
Neurological conditions such as Parkinson’s disease or multiple sclerosis?	Yes No Unsure
Any other medical conditions?	Yes (Please specify) _____________________ No Unsure

2. Prior to the incident, were you taking any medication? This includes medication prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives.

Yes

No

Don’t Know

3. Do you currently smoke cigarettes, cigars, or pipes?

Yes

No Go to Question F6

Don’t Know/Refuse to answer

4. Have you smoked on a daily basis in the past?

Yes

No

Don’t Know/Refuse to answer

4. On average, how many of that product do you currently smoke each day?

Please specify: ________________________

If respondent is male, go to next module

4. Are you currently pregnant?

Yes

No

Don’t Know

4. Are you currently breastfeeding?

Yes

No

General Survey Module: Occupation

1. Are you currently employed. This includes part-time and full-time jobs that lasted one month or more, such as jobs for pay inside or outside the home or jobs on a farm?

Yes

No skip to next module

2. What is your occupation? If unknown probe for a specific description of their main duties_________________

3. Who is your employer? Probe for company name and city _________________

4. Did you respond in any way to this incident If yes and necessary, probe.

Yes

Not a responder Go to next module

2. Are you a volunteer or career responder?

Volunteer

Career responder

3. At the time of the incident, how long had you been working in that role? (e.g., firefighter, police, recovery worker etc.)

____ Years ______ Months

4. Prior to incident, were you trained to respond to an incident of this nature?

Yes

No

5. Were you trained on PPE usage, including types and how to properly don/remove your PPE?

Yes

No

6. Is PPE readily available to you?

Yes

No

Unsure

__________________________________________________________________

7. Please look at this list and tell me what level of PPE you were wearing when you responded to the incident

If Responder type Volunteer firefighter through Company Responder ask . Present Showcard Side A.

None

Level “A”

Level “B”

Level “C”

Level “D”

Firefighter turn-out gear with respiratory protection.

Firefighter turn-out gear without respiratory protection.

Other types of protection (such as gloves, eye protection, hardhat, steel-toed shoes)

If selected, ask: Please specify the type of protection:

If Responder type is Hospital worker or EMS worker or other ask Present Showcard Side B

None

Non-sterile exam gloves

Surgical gloves

Face mask without protective shield

Face mask with protective shield

Non-splash resistant disposable gown

Splash resistant disposable gown

Protective eye glasses/goggles

Supplied air respirator

Respirator with cartridge/HEPA filters

Other-specify the type of protection:

7. Did you need to stay home from work or miss work due to symptoms you experienced after the incident?

Yes Ask how many days did you miss?_________days

No

Unsure

7. Did you need to modify your regular work duties due to symptoms you experienced after the incident?

Yes Ask how many days of modified work duties did you need?_________days

No

Unsure

7. What, if anything, could have been done differently to improve the response?

General Survey Module: Communication and Needs

Now I would like to ask you a few questions about the communication you may have received regarding the incident.

Fill in the table below. Ask i and only check the box next to the type of information the respondent received first. Then follow-up with ii-iii for the information the respondent received first. Then continue to next table.

Source of Information	How did you first receive information about the incident? Check only one box.	ii How soon after incident did you receive instructions (minutes)? Was the information Minutes	iii.Was the information Sufficient/helpful sufficient/helpful? Write yes, no, or DK (for don’t know)
Directly from person in authority (i.e. police, firefighter, Hazmat official, supervisor)
TV
Radio
Two-way radio
Newspaper
Relative/friend/neighbor/ coworker
Website
Social Media
Reverse 911 call
Phone call
Text message on a cell phone
Email
Community Meeting
Other, Specify:

Ask i and only check the box next to the type of follow-up information the respondent received. Then ask ii-iii for each information source before moving to the next source.

Source of Information	i. How did you receive follow-up information about the incident? Check all that apply.	ii.How soon after incident did you receive instructions (minutes)	iii.Was the information sufficient/helpful? Write yes, no, or DK (for don’t know)
Directly from person in authority (i.e. police, firefighter, Hazmat official, supervisor)
TV
Radio
Two-way radio
Newspaper
Relative/friend/neighbor/ coworker
Website
Social Media
Reverse 911 call
Phone call
Text message on a cell phone
Email
Community Meeting
Other, Specify:

2. In the future, what are the best ways for your local authorities or the health department to reach you with information regarding an incident? Check all that apply:

TV

Radio

Newspaper

Website

Social Media

Phone call

Text message on a cell phone

Email

Community meeting

Other (Please specify):

3. As a result of this incident, are you personally in need of anything? (check all that apply)

 Medicine or medical supplies

 Medical care

 Mental health care

 Water

 Shelter

 Food

 Utilities

 Transportation

 Other, specify _________________________________

 Don’t know/refused

4. What is your current address?

Street Apt

City State __ __ Zip Code:

5. What is the best telephone number to reach you? Please specify if this is a cellular phone, house phone, or work phone.

( __ __ __ ) __ __ __ ‑ __ __ __ __

Cell

House

Work

6. Are there any more telephone numbers where you can be reached?

If yes, collect all other numbers and specify whether cell, house, or work number.

( __ __ __ ) __ __ __ ‑ __ __ __ __

Cell

House

Work

7. Do you have an email address where you can be reached?

Yes

No Go to Q8

What is your email address?

8. We may want to interview you again in the future to check up on your health. Keeping in mind that people move, we would like to get a little more information to help us locate you in the future. In case you move to another residence, could we have the name and contact information of a person who live outside of your household and who would always know how to find you?

Yes  Complete the table provided

No  Go to next module

	Person 1
First and Last Name
Address
Phone Number (including area code)
Email Address
Relationship to you (parent, child, sibling, other relative, friend, other)

General Survey Module: Exposure of Other People Present

1. Were there any other individuals present with you in the highlighted area of the map during the incident? Show highlighted area of the map.

Yes

No  Go to next module

2. In order to accurately evaluate the impact of the incident, we are trying to interview as many people who were in the area as possible. Fill in the following table with the information given for Question a-c.

   1. Can you tell me the names of everyone else who was present with you during the incident?

   2. Which are children, and what are their ages?

   3. Can you tell me the phone number and e-mail address of the people who do not live with you?

Name	Age (if child)	Phone	E-mail

General Survey Module: Demographic and Contact Information

Now, I have some general questions about you.

1. Do you identify as male, female, or other?

Male

Female

Other

2. What is your date of birth?

____/____/______
MM DD YYYY

3. Do you consider yourself to be Hispanic or Latino?

Yes

No

Refused or unknown

4. What race do you consider yourself to be?

Check all that apply:

Black or African American

White

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

5. What is the highest level of education you completed?

Grade 8 or Less

Some High School

High School Graduate or Equivalent

Some University/College

Technical or Trade School

Junior or Community College

University/College Graduate

Graduate School or Higher

Conclusion Statements

1. Is there anything that we did nto cover that you want to tell us related to the incident?

2. If Exposure of Other People Present Module did not identify children under the age of 13 that were present, go to Closing Statement. If children under the age of 13 were identified, read: I would now like to ask you some questions regarding any children you have under the age of 13 that were with you when you were in the highlighted areas of the map.

Refer to Exposure of Other People Present Module to recall child’s name and then go to the Child Survey Section

Closing Statement:

That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.

Child’s Name: ________________________________________ Participant ID _________

Child Survey Module: Location/Exposure

1. Did [Child’s name] evacuate from the highlighted area on the map?

Yes

No

2. At approximately what time did he/she evacuate?

____:_____ AM PM

Hour Min

3. How did he/she evacuate?

Ambulance

Privately-owned vehicle

Bus

Other (Please specify):

4.Was [Child’s name] decontaminated, meaning their clothing was removed or their body was washed?

Yes

No Go to next module

5.How was [Child’s name] decontaminated? Read all answer choices aloud to the respondent and check all that apply.

Clothing Removal

Water

Soap and Water

Other (Please specify):

6. Where was [Child’s name] decontaminated? If respondent needs clarification, specify that this question is asking for a geographic location, not a place on their body. Read all choices to the respondent.

Community reception center (CRC)

Mobile decontamination unit

Emergency room (ER)

Other (Please specify):

6. At approximately what time was [Child’s name] decontaminated?

_____:_____ AM PM

Child Survey Module: Health Status after the Incident

I’m going to ask some questions about symptoms that could be related to the [Incident]. Fill out the table provided below. Check the boxes that apply before asking about the next symptom.

	Did [Child’s name] experience [Symptom] since the incident? If yes, go to ii. If no, repeat i for next symptom.		If [Child’s name] experienced this [Symptom] before the incident did it get worse?		Is [Child’s name] still experiencing [Symptom]? Repeat i for next symptom.
	Yes	No	Yes	No	Yes	No
GENERAL
Fever
Chills
Generalized weakness
Body pain
Severe bleeding
EYES
Increased tearing
Irritation/pain/ burning of eyes
Blurred vision/double vision
Bleeding in eyes
EAR/NOSE/THROAT
Runny nose
Burning nose or throat
Nose Bleeds
Hoarseness
Increased salivation
Ringing in ears
Difficulty swallowing
Swollen neck
Pain in jaw
Odor on breath (Gasoline or other, specify)
Stuffy nose/sinus congestion
Increased congestion or phlegm
NERVOUS SYSTEM
Headache
Dizziness or lightheadedness
Loss of consciousness/fainting
Seizures or convulsions
Numbness, pins and needles, or funny feeling in arms or legs
Confusion
Difficulty concentrating
Difficulty remembering things
Concussion
Loss of balance
MUSCLE/JOINT/BONES
Weakness of arms
Weakness of legs
Joint swelling
Muscle weakness
Muscle twitching
Tremors in arms or legs
Joint pain
Broken bone/fracture
Dislocation
Sprain or strain
Whiplash
HEART AND LUNGS
Breathing slow
Breathing fast
Difficulty breathing/feeling out-of-breath
Coughing
Wheezing in chest
Slow heart rate/pulse
Fast heart rate/pulse
Chest tightness or pain/angina
Bronchitis
Pneumonia
Burning lungs
STOMACH/INTESTINES
Nausea
Non-bloody vomiting
Non-bloody diarrhea
Bloody vomiting
Blood in stool/diarrhea
Abdominal pain
Fecal incontinence or inability to control bowel movements
Bowel perforation
SKIN
Irritation, pain, or burning of skin
Skin rash
Hives
Skin blisters
Bumps containing pus
Nail changes
Hair loss in area of rash
Hair loss
Dry or itchy skin
Sweating
Cool or pale skin
Skin discoloration
Poor wound healing
Petechiae/Pinpoint round spots
Blue coloring of ends of fingers/toes or lips
Lips turning blue
Abrasion/scrape
Bruise
Cut
KIDNEY/BLADDER
Urinary incontinence or dribbling pee
Inability to urinate or pee
Blood in urine
Painful urine
PSYCHIATRIC
Anxiety
Agitation/irritability
Thoughts of suicide
Fatigue/tiredness
Difficulty sleeping
Difficulty staying asleep
Feeling depressed
Hallucinations
Paranoia
Unexplained fear
Tension or nervousness
Any other symptoms? If yes, What was it? Record below.
1.
2.
3.
4.

Child Survey Module: Medical care

1. Did [Child’s name] receive medical care or evaluation because of the incident?

Yes  Go to Question 3

No

2. Why didn’t you seek medical care for [Child’s name]?

Did not have symptoms    

Symptoms were not bad enough    

Don’t like to go to the doctor

Didn’t want to take time

Worried about who would pay for the medical visit

Worried about losing job

Other (Please specify): ______________________________________________________

Unsure

For those individuals who did not seek medical care for the child, go to the next module.

3. Please tell me if any of the following describe why [Child’s name] sought medical care. Read questions a-c to the respondent and circle the appropriate answer(s).

1. You were given instructions to seek medical care? Yes No Unsure

2. You experienced health problems or symptoms
   within 24 hours of the incident? Yes No Unsure

3. You were worried about possible health
   problems associated with the incident? Yes No Unsure

4. How did [Child’s name] receive medical care?

EMT or paramedic

Hospital  Go to Question 5

Doctor or other medical professional  Go to Question 14

5. On what date was [Child’s name] first provided care at a hospital? If he/she had any additional visits to the hospital, please provide me the dates of those visits. Record the date that the child first went to the hospital and then the date of any subsequent visits.

1^st date of hospital visit: ____/____/______

MM DD YYYY

2^nd date of hospital visit: ____/____/______

MM DD YYYY

3^rd date of hospital visit: ____/____/______

MM DD YYYY

6. What is the name and city and state of the hospital(s)?

Hospital Name 1 __________________HCity 1__________HState 1__ __

Hosptal Name 2___________________HCity 2__________HState2 __ __

Hospital Name 3___________________HCity 3__________HState3__ __

7. How did [Child’s name] get to the hospital? If the child had more than one hospital visit, tell the respondent that you are referring to the child’s first visit.

EMS/Ambulance

Driven by relative, friend, or acquaintance

Other (Please specify):

8. Was [Child’s name] treated only in the emergency department or was he/she admitted to the hospital?

Treated in an emergency department (Outpatient)  Go to Question 14

Admitted (Hospitalized)

9. How many nights was he/she hospitalized, including any nights in an intensive care unit (ICU)?

________Nights

10. Was he/she placed in an Intensive Care Unit or ICU?

Yes

No  Go to Question 14

11. How many nights was he/she in the ICU?

________ Nights

12. Was he/she on a ventilator?

Yes

No  Go to Question 14

13. How many nights was he/she on a ventilator?

________ Nights

14. Read i–iv to the respondent and record information in the table below.

On what dates was [Child’s name] provided care by a doctor or other medical professional? (mm/dd/yyyy)	What is the name of the doctor or medical professional?	What service did this doctor or medical professional provide?	What is the address of the office?

Child Survey Module: Medical History

Now I’m going to ask you a few questions about illnesses your child may have had and the kinds of medicines he/she may have used.

1. Prior to the incident, have you ever been told by a doctor or other health care provider that [Child’s name] has any of the following medical conditions? Fill out the table below. Circle appropriate response and ask the respondent to specify as directed.

Medical Condition
a. Allergies?	Yes (Please specify) ______________________ No Unsure
b. Asthma?	Yes No Unsure
c. Depression?	Yes No Unsure
d. Anxiety?	Yes No Unsure
e. Diabetes?	Yes No Unsure
High blood pressure?	Yes No Unsure
Chronic obstructive pulmonary disease (COPD) or emphysema?	Yes No Unsure
Heart Disease?	Yes No Unsure
Physical disability that hinders mobility?	Yes (Please specify)_______________________ No Unsure
Psychological condition such as anxiety, depression or dependence disorder?	Yes (Please specify) ______________________ No Unsure
Cancer?	Yes (Please specify) _____________________ No Unsure
Immune disorders such as lupus, rheumatoid arthritis, or HIV?	Yes No Unsure
Neurological conditions such as Parkinson’s disease or multiple sclerosis?	Yes No Unsure
Any other medical conditions?	Yes (Please specify) _____________________ No Unsure

Prior to the incident, was [Child’s name] taking any medication? This includes medication prescribed by a health care provider and those you might have gotten without a prescription from stores, pharmacies, friends, or relatives.

Yes

No

Don’t Know

Child Survey Module: Demographic Information

Now, I have some general questions about [Child’s name].

1. Does [Child’s name] identify as male, female, or other?

Male

Female

Other

2. What is [Child’s name] date of birth?

____/____/______
MM DD YYYY

1. Do you consider [Child’s name] to be Hispanic or Latino?

Yes

No

2. What race do you consider him/her to be?

Check all that apply:

Black or African American

White

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

3. What is [Child’s name] current address?

Street Apt

City State __ __ Zip Code:

Child Survey Module: Concluding Instructions

If there are more children under age 13, get a new child survey and ask about next child.

Closing Statement:

That completes this survey. I would like to sincerely thank you for your time. Be sure to record the end time on the first page of this survey.

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